1912447434 NPI number — OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH

Table of content: (NPI 1912447434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912447434 NPI number — OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OFF THE GRID MIDWIFERY AND WOMEN'S HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912447434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6002 WESTGATE BLVD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98406-2570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-509-2960
Provider Business Mailing Address Fax Number:
253-292-1045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6002 WESTGATE BLVD
Provider Second Line Business Practice Location Address:
SUITES 270 & 274
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98406-2570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-509-2960
Provider Business Practice Location Address Fax Number:
253-292-1045
Provider Enumeration Date:
03/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER, ADMINISTRATOR
Authorized Official Telephone Number:
253-509-2960

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  AP30003731 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12013042 . This is a "CAQH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1780661694 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9620246 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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